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Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services (2021)

Chapter: Chapter 2 - Why Should Communities Improve Transportation to Health Care?

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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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Suggested Citation:"Chapter 2 - Why Should Communities Improve Transportation to Health Care?." National Academies of Sciences, Engineering, and Medicine. 2021. Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services. Washington, DC: The National Academies Press. doi: 10.17226/25980.
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9 Introduction Access to health care is critical for promoting and maintaining health, preventing and managing diseases, and working toward health equity for all Americans (1). Transportation has a significant role in that access and has been called fundamental to societal health (2). With available and timely transportation, individuals can travel in their commu- nities to access the medical appointments and services they need. Without that access, care is delayed or missed, increasing not only the potential for poor health outcomes but also the cost for health care. Particularly for those with chronic diseases, delays in care and missed appoint- ments complicate disease management and may worsen patients’ health, which increases over- all health-care expenditures. Transportation: A Social Determinant of Health For many years, efforts to improve health in the United States focused on the health-care system as the primary factor driving health and health outcomes. However, more recent research increas- ingly recognizes that it is not just the health-care system—it is a range of factors that drive health and health outcomes (3). These factors—the social determinants of health—are “the structural deter- minants and conditions in which people are born, grow, live, work and age” (3); see Exhibit 2-1. These efforts include not only transportation but also such factors as economic stability, employment, housing, education, and social support networks. These are elements that help structure the communities where we live. Communities that recognize these factors and address deficiencies can help mitigate health disparities that often arise from social and economic dis- advantages (4). Efforts to combat these disparities in health care typically focus on population groups that are impacted, including people with low incomes, older adults, individuals with disabilities, and those living in rural and inner-city areas (4). What Is the Role of Transportation? Remarks at a workshop on the intersection of health care and transportation speak to trans- portation’s larger role in society and its role in health care (5): C H A P T E R 2 Why Should Communities Improve Transportation to Health Care? Transportation does not exist to serve itself. Transportation really exists so that we can [try] to achieve other more important things in life and in society. Things like improving the economy; things like improving quality of life. And I think more and more we are starting to recognize that transportation has a role in terms of supporting public health as well.

10 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Transportation ensures a community’s connection to health-care services, and a lack of transportation is often cited as a barrier to health-care access (6). Little data exists on exact numbers of people who lack transportation access to health-care services. Data suggest a range as great as 10% to 50% of patients report transportation as a barrier to accessing health care (6). This wide variation in the data may be due to differ- ing user groups or a lack of consistency in the measurement and defining of “transportation barriers,” which makes it difficult to determine the full impact that transportation barriers have on health outcomes (7). Transportation issues in accessing health care are generally related to transportation costs, lack of access to a vehicle or public transit, distance and time-related burdens, disabilities that prohibit the use of public transit, safety and infrastructure issues, and adverse policies (8). These are depicted in Exhibit 2-2. Vehicle access, such as owning a car or having access to a car via a friend or family member, has a positive relationship on the ability to access health care (6). Studies have found that vehicle access may lead to fewer missed appointments (9, 10). Patients also cite the burden of travel distance and time as a barrier to accessing health care (11). Although rural geography may come to mind when considering long travel distances, even urban residents with access to public transit services still face barriers. Urban and rural residents living in less centralized locations who use public transit may have to rely on limited transit service that requires them to make multiple connections or walk significant distances (11). Transportation infrastructure and driver’s license issues may also place significant barriers on accessing health care. For example, inaccessible pathways, bus stops, or stations, limited routes or availability, and driver’s license laws can impact the ability to access health care (12, 13). Exhibit 2-1. Social determinants of health (3).

Why Should Communities Improve Transportation to Health Care? 11 The Need for Transportation to Health Care A comprehensive review of the research on transportation’s role in health-care access comes from a report on the Rides to Wellness Community Scan Project (14). Findings include: Exhibit 2-2. Transportation issues impacting health-care access (8). Lack of transportation can cause patients to miss medical appointments, disrupting the continuity of care and causing delays in the delivery of necessary health and wellness services. Research indicates that lack of transportation is a barrier to health care for various segments of patients, including rural veterans (Buza et al., 2011); low-income immigrants in suburban communities (Silver, Blustein, & Weitzman, 2012); patients with chronic disease (Guidry, Aday, Zhang, & Winn, 1997); poor and low-income adults (Ahmed, Lemkau, Nealeigh, & Mann, 2002); and children and families (Children’s Health Fund, 2011). Access to reliable and affordable transportation is associated with increased utilization of health services, improved health outcomes, and greater likelihood of primary care visits by the pediatric population, adults living with HIV, and frequent users of emergency departments (Kim, Norton, & Stearns, 2009) (15).

12 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services The Rides to Wellness Community Scan Project goes on to find: • Rates of missed appointments vary widely across health-care sites. • Demographic factors, such as race, ethnicity, and income status, are associated with missed appointments. • Not having access to a car is independently associated with missing appointments. • Transportation is frequently identified as a barrier to health-care utilization. • Some populations are at higher risk of missing appointments due to transportation barriers. • Costs associated with missed appointments due to transportation barriers have not been established in the empirical literature. Research published in 2005 found that 3.6 million transportation-disadvantaged individuals miss at least one medical trip per year due to transportation barriers (16). Transportation Barriers: A Factor Affecting Health-Care Disparities Health-care disparities exist across many dimensions, including socioeconomic status, age, geography, disability status, rural locations, Medicaid, and needs of Native Americans and veterans. Socioeconomic Status Patients reporting a lower socioeconomic status typically report higher rates of transportation barriers that impact access to health care (6). Research has found that those patients who have problems with transportation to health care are poorer, older, and are more likely to be female and non-white compared to the U.S. population as a whole (16). In a survey of an ambulatory children’s health clinic serving mostly lower-income and Medicaid patients, 51% of parents stated that transportation barriers (no vehicle or access to a vehicle) were the reason for missing their child’s scheduled appointment. The missed appointment rate was 34% (17). Older Adults The American population is aging; therefore, as the number of older adults increases, so too will the demand for transportation services (18). Age-related changes such as cognitive and physical declines may also lead to missed health-care appointments, ultimately affecting progression and management of disease (19). Even when older adults have access to public transportation, using it may require some level of physical fitness, the ability to follow bus route directions, and the capability to navigate complex bus transfers (20). Individuals with Disabilities and Mobility Limitations People with disabilities face challenges in accessing transportation. Barriers may be related to the inability of the person to operate a vehicle, inability to access pathways or public transit, or because the public transit that is available does not fit their particular needs. For fixed-route public transit, the pedestrian infrastructure is a barrier in many cases. If the bus stop and/or pedestrian pathways are inaccessible or unsafe, fixed-route public transit is not an option for individuals with disabilities.

Why Should Communities Improve Transportation to Health Care? 13 Individuals with disabilities also experience higher rates of poverty than those without dis- abilities, compounding their difficulties in accessing health care. Data for the age group 18 to 64 show that those with disabilities experience a poverty rate that is more than twice that of people without a disability: 29% versus 12% (21). Rural Populations Transportation is frequently mentioned by rural residents as a major barrier in accessing health care (22). Characteristics such as low population density, long distances, and isolation that is typical of rural areas can affect how residents access services. Public transportation may be available but can be inadequate in rural communities and towns, which may increase reliance on using a personal vehicle. Even when public transit exists in such areas, service is typically limited because of insufficient funding and often an ineffective service design. In some cases, rural roads may be in disrepair or not easily traversed, and long distances to access health-care services require extended travel time (23). On a large Navajo reservation in rural Arizona, for example, one may travel over 200 miles round trip to get to a specialist or 100 miles round trip simply to access a health clinic or hospital (24). Approximately 15% of rural residents have a disability (25). People with disabilities living in rural communities face additional barriers to accessing transportation, including a lack of accessible vehicles and safe access to pick-up and drop-off locations. A critical issue for rural communities is the loss of rural hospitals. The number of rural hos- pital closures has increased significantly in recent years, and this trend is likely to continue, with impacts on residents’ access to health-care services (26). The Government Accountability Office (GAO) reports that 64 rural hospitals closed between 2013 and 2017, a rate that is more than twice the number of closures in the preceding 5-year period (27). Rural hospitals are closing due to factors that include a patient base that is aging, poor, and shrinking; high uninsured rates and a payer mix dominated by Medicare and Medicaid; economic challenges in the community; aging facilities; outdated payment and delivery system models; and business decisions by corporate owners/operators (26). Patients served by these hospitals tend to have more complex health conditions. Research shows, for example, that 18% of people are age 65 and older in rural communities compared with 14% in urban areas, and 18% have limitations due to chronic conditions compared with 13% in urban communities. These patients require more services and more specialties than younger, healthier patients. As rural hospitals close, such residents of rural communities are more likely to delay health care or even forego needed care (26). Medicaid Beneficiaries Over 20% of Americans who live in low-income households or have disabilities are enrolled in Medicaid (28). As Medicaid beneficiaries, they may be eligible to obtain Medicaid non- emergency medical transportation (NEMT) for transportation to covered medical services with primary care and specialty health-care providers. TCRP research estimated that Medicaid NEMT provided close to 104 million trips in FY 2013 for a cost of $2.9 billion (29). Such transportation is critical for this population group: research based on National Health Interview Survey data has found that primary care access by Medicaid beneficiaries was dispro- portionately affected by limited transportation compared to those with private insurance (30).

14 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Reimbursement for Medicaid NEMT varies by state. Several states use prior approval pro- cesses or limit the number of trips allowed per month, while other states contract with local community agencies, vendors, individual drivers, or brokers to coordinate services. Some states use volunteers who are reimbursed for their mileage. States may pay taxicab companies or other commercial transportation firms on a mileage or trip basis. The differing state parameters and approaches for Medicaid NEMT may create transporta- tion barriers for the vulnerable population groups. Through the Affordable Care Act (ACA), at least three states—Iowa, Indiana, and Kentucky—have received federal waivers to cut Medicaid transportation services, and Massachusetts has a waiver pending. Other states are exploring waivers to reduce NEMT costs to their Medicaid programs. According to a 2009 study conducted for the Texas Medicaid program, unmet need for transportation is rising and remains stubbornly high (31). The average number of recipients in the state’s Medicaid program for children with unmet transportation needs showed steady increases during the study period in 2008 to 2009. By the end of 2009, those with unmet trans- portation needs remained well above 20%. Native Americans Native American transportation needs vary by geography and are far from homogenous. Some tribes, such as the Navajo and Hopi, live in very rural environments and often have trips of well over 50 to 75 miles each way to access health care, making transit service difficult to operate, with significant logistical issues and consequently with high operating costs (32). Other tribes or pueblos in close proximity to urban areas—for example, Tesuque and Pojoaque pueblos outside Santa Fe, New Mexico—require service similar to any other suburban or urban community, with less challenging logistical issues than in the more isolated areas. Veterans To a great extent, veterans have transportation needs similar to non-veterans. While many transportation needs of veterans overlap with those of the general public, there are some differences (33). Approximately 40% of veterans use the health-care services of the Depart- ment of Veterans Affairs (VA), and often this requires significant travel, particularly for those veterans living in rural areas (33). A recent report commissioned by the VA evaluated the department’s transportation pro- gram for veterans—the Veterans Transportation Service (VTS) established at certain VA medi- cal centers. This report notes that the transportation needs of veterans may relate to the nature of active duty experiences that result in certain physical and mental conditions less common in civilian patients (34). For example, veterans with post-traumatic stress disorder (PTSD) may have difficulty traveling in crowded or noisy situations. Their conditions may require unique considerations for transportation (34). Issues Facing Health-Care Providers in Improving Access to Health Care Health-care providers have a role in improving transportation access to health care, but they first must understand the role of transportation and barriers that might confront their patients. The ACA has been a catalyst in helping the health-care industry understand the importance of transportation as one of the social determinants of health.

Why Should Communities Improve Transportation to Health Care? 15 Health-care providers can also take action by sharing information about existing transporta- tion programs available to their patients. A more direct approach is to actually provide or fund patient transportation, a strategy now explicitly allowed by 2016 revisions to federal law that governs regulations for health-care providers (35). Communication with Patients About Transportation Effective communication with patients to understand their health-related social needs can address transportation issues and improve access to health care. This involves recognition of the social determinants of health, and it can lead to transportation improvements. Standardized Screening for Health-Related Social Needs Screening patients for their social needs would help the health-care industry understand the important role that transportation plays in access to health-care services, but such screening is not yet standard clinical practice (36). One of the ACA’s new models of health care—the Accountable Health Communities Model—is addressing this gap between clinical care and patients’ social needs by testing whether identifying and addressing health-related social needs improves patients’ health and impacts health-care costs (37). This model specifically attempts to support clinical and community partnerships. Hospitals, clinics, and other medical facilities serve as the entry point for the model by screening Medicare and Medicaid patients for their unmet social needs across what is defined as “five core domains.” Transportation is one of the five. Exhibit 2-3 shows the questions for the transportation topic. The five domains were chosen for several key reasons, one of which is that the need can be met by community service providers. There are currently 31 organizations testing the Accountable Health Communities Model. It remains to be seen if community service providers can actually respond and improve trans- portation to health care if transportation is identified as one of the core social needs. Community Health Needs Assessments Addressing the social determinants of health can be approached in a broader way— through an assessment of a community’s social needs. This is another strategy of the ACA. In addition to testing new models of health care, the ACA now requires certain hospitals to conduct what are known as “community health needs assessments (CHNAs)” every 3 years. The objective of these assessments is to identify the barriers to improving community health and then to develop an action plan to address those barriers. This requirement applies to private, non-profit hospitals, which comprise about 60% of all hospitals in the country (39). Transportation Needs 5. In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work, or from Yes, it has kept me from medical appointments or getting medications Yes, it has kept me from non-medical meetings, appointments, work, or getting things that I need No getting things needed for daily living? (Check all that apply) Exhibit 2-3. Transportation-related questions of the accountable health communities core health-related social needs screening questions (38).

16 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services To conduct a CHNA, hospitals are required to (39): • Identify the significant health needs of the community, prioritize those needs, and identify potential measures and resources available to address the needs. • Include input from “persons representing the broad interests of the community.” • Provide an implementation strategy addressing each significant health need identified. Hospitals are encouraged to collaborate with other community organizations and facilities. The Association for Community Health Improvement has developed a nine-step process for developing a CHNA (40); see Exhibit 2-4. Transportation has not been a key feature of CHNAs to date, with CHNAs focusing more on health conditions, behaviors, and clinical care (39). This may be due to perceptions that transportation and other social determinants of health are beyond the purview of a hospital. Those CHNAs that did address some of the social determinants of health often did not attempt to address them in their required implementation strategy, possibly because such issues are long-term problems. The National Center for Mobility Management suggests that community-based mobility managers can work with hospitals in developing their CHNAs and help them address transpor- tation needs and problems that may be identified. Exhibit 2-4. Nine-step pathway for conducting a CHNA and developing implementation strategies (40).

Why Should Communities Improve Transportation to Health Care? 17 Information About Available Transportation Options Another information-sharing strategy involves marketing existing transportation programs to build ridership and community buy-in, especially for new transportation programs. Health-care providers and patients may not be aware of what transportation services are available or may not be fully educated on how to use those services. Information on eligibility, cost, hours, and other critical details should be widely disseminated so potential users may utilize the service. Awareness-raising campaigns should be created in order to educate both community resi- dents and providers on how to access available transportation (41). One of the case studies included in Chapter 5 of this report provides an effective example of how such information sharing benefits and improves access to health care. This is often a mobility management func- tion as is typified by Capital Metro in Austin, Texas, and its rural partner, Children and Adults Rural Transportation Service (CARTS). Patient Transportation Revisions to federal law relating to prohibitions of “kickbacks” in the Medicare program specifically address the ability of health-care providers to provide transportation for patients with a ruling in December 2016—Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements (35). With the ruling, “eligible entities,” which include health-care providers such as hospitals and clinics (but excluding entities that primarily supply health-care items such as pharmacies), are allowed to fund local, non-emergency transportation for patients and shuttle services for patients and others to access medically necessary services and items within specific parameters. The transportation can be free or discounted. Health-care providers and unrelated businesses may contribute together to provide the transportation. The ruling defines the details. • What types of transportation can be provided? Transportation can be provided on a door- to-door basis as well as shuttle transportation service. Health-care providers can provide the transportation or use vouchers or other subsidy methods to provide transportation for patients. • What does local mean? Local transportation is defined as up to 25 miles in urban areas and 50 miles in rural areas. • Who can be served? Individualized transportation (door-to-door) is to be provided for “estab- lished patients” including anyone who has made their first appointment. In various communities, health-care providers, including hospitals, have provided direct support for patient transportation before the 2016 ruling, through in-house van service, allow- ances, special arrangements, or waivers from the Anti-Kickback Statute. Now, however, the revisions to the statute clear the way for health-care providers to directly improve transporta- tion for their patients. The Business Case for Improving Transportation Access to Health Care Making the business case for transportation is primarily targeted to health-care providers. For transportation providers, the currency is ridership, and new ways to generate ridership makes the case for itself. Public transit providers are always looking to generate more fixed- route ridership by selling passes and tickets to health-care providers. Private providers such as

18 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services transportation network companies (TNCs) and taxis understand this and actively pursue con- tracts and agreements with health-care providers. These and more examples will be discussed in detail in Chapters 4, 5, and 6. The Business Case for Health-Care Providers The business case for health-care providers is a little less straightforward. Most of the research finds that improved access to health care will provide for greater patient encounters. Research also indicates that improved access to transportation can contribute to reduced missed appointments. Research regarding transportation for veterans reported that, after a reimbursement rate increase, eligible veterans were 6.8% more likely to have an outpatient encounter, noting that the policy change was successful in increasing access to VA care for patients. The urban and rural changes were similar (42). Other studies have demonstrated increased compliance with health-care visits after receiving taxicab vouchers (17, 43). Researchers have speculated that the corresponding improved rates of follow up may be related to the psychosocial impacts—receiving taxi vouchers or bus passes conveyed a sense of urgency for follow up or a sense of commitment from staff (43). A recent study conducted among Medicaid patients had interesting results in an attempt to improve access and reduce missed appointments (44). The study’s authors asked the question: What is the association between offering TNC-based transportation services (e.g., Uber, Lyft) as opposed to the existing Medicaid NEMT network and missed appointment rates for primary care patients? In other words, does the use of TNCs improve the missed appointment rate over the use of the existing Medicaid NEMT network? This clinical trial found that the missed appointment rate was not significantly different between patients offered TNC transportation services compared with those that received regular Medicaid NEMT. In essence, the use of TNCs produced similar results to the existing NEMT network that patients were using. Transportation Is Cost Effective Missed appointments and the related postponement of care costs the U.S. health-care system up to $150 billion annually (45). Health-care providers lose revenue when patients miss appointments, and health-care costs may rise due to increased emergency department visits resulting from postponed care. In addition, patients and third-party payers (including com- mercial insurance, Medicare, and Medicaid) end up paying more when care is inappropriately sought in the emergency department. In an effort to reduce expensive and ineffective care, new alternative health-care payment and delivery models are being implemented through changes in the health-care system imple- mented by the ACA. These changes shift health-care incentives from a volume-based system to a value-based system whereby providers are incentivized to provide cost-effective care. Cost effectiveness is foundational to the ACA’s new alternative health-care payment and delivery models, such as accountable care organizations (ACOs). An ACO is comprised of a group of physicians, hospitals, and health-care providers who join together to provide coordi- nated, high-quality care to the patients they serve (46). Coordinated care is intended to support patients getting the right care at the right time. When an ACO is effective in delivering high-quality care and reducing costs, it will share in the savings it achieves for the payer (e.g., commercial insurance, Medicare, Medicaid). Although ACOs are not paid to provide transportation, some ACOs are serving as a central hub to engage with community organizations to provide transportation for patients to access

Why Should Communities Improve Transportation to Health Care? 19 health-care services (47). In a survey of ACOs, 84% of respondents indicated that transporta- tion services were needed to improve the overall health of the communities they serve. In addi- tion, one out of 10 ACO respondents indicated they are offering or planning to offer trans portation services to increase access to health-care and social services. ACOs recognize the role that trans- portation plays in reducing health-care costs and improving patient outcomes. In a study conducted by Florida State University, researchers found that if one out of every 100 trips prevented a 1-day stay in the hospital, the return on investment would be 1,108%, a payback of $11.08 for every dollar invested by the state of Florida in funding medical mobility programs (48). While it may require policy-level or practice-level changes, addressing trans- portation issues in health care on a larger scale can be cost effective in certain situations (7). A comprehensive study of the VA’s VTS has found cost savings to the VA in several ways (34). • Using its own in-house, VTS resources to provide trips avoided the VA’s cost of using out- sourced services provided by third-party vendors. • A decrease in missed medical appointments due to patient cancellations was shown in VA medical centers with a VTS program. Those centers showed a decrease in the percent of cancelled appointments of 3.5 times greater than medical centers without a VTS program. • Timely discharges from in-patient hospital stays were possible where VA medical centers with a VTS program were able to transport patients who were discharged from the hospital but lacked transportation. Without transportation, such patients would otherwise require another (unjustified) hospital stay. One of the VA medical centers calculated a savings of almost $500,000 in 6 months from the use of its VTS vehicles to take patients home at the time of discharge, avoiding the costs for additional days in the hospital. • The number of emergency department visits by patients who used VTS services decreased by a greater share than comparable patients without transportation who did not use VTS services. What Can Communities Do to Improve Transportation to Health Care? Communities can—and have done so in various examples around the country—take an active role or become an involved participant in planning for improved transportation access to health care. This research project has recognized examples of strategies identified in the literature as well as through outreach and surveys conducted by the research team. A number of these strategies are listed below, with more information and discussion of examples provided in Chapters 5 and 6 of this guide. • Coordinate community planning between public transportation and health-care providers to prioritize needs assessments and data about transportation barriers to health care (2). Trans- portation and health-care providers should engage early in the process. • Support the role of mobility management to coordinate transportation options for com- munity residents facing transportation problems in seeking health care (49). • Design and provide effective and high-quality public transit for the community, which can reduce the need for more costly specialized transportation service. • Work with the state’s Medicaid agency to ensure that safe and accessible Medicaid NEMT is available with vetted and trained drivers and without undue restrictions for those beneficiaries who do not have reliable and affordable transportation access to health care. • Explore available federal programs and grants that may support improved transportation to health care. One example is the Racial and Ethnic Approaches to Community Health (REACH) grants that support community-focused interventions to reduce specific neighborhood- based health-care disparities by engaging local leaders, building community partnerships, and creating sustainable programs (4).

20 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services • Seek support from foundations that focus on improving access to health care for vulner- able population groups. There are a number of examples that depend on support from local hospitals or medical center foundations. • Identify community and health-care organizations that understand that transportation is a barrier to health care and work toward cooperative arrangements with those organizations to plan transportation solutions. • In rural areas, reduce costs for transportation to health care by channeling ridership to a set schedule to the extent possible, as opposed to providing more personalized one-on-one trips that are more costly. Summary The availability of transportation influences the ability of individuals to access health care, whether in urban, suburban, or rural areas. Those lacking appropriate or available transpor- tation miss health-care appointments, resulting in delays in receiving medical interventions, which may then lead to poorer health outcomes. This in turn contributes to the rising cost of health care. Research has found that access to reliable and affordable transportation is associated with increased utilization of health services and improved health outcomes; that improved access to health care will provide for greater patient encounters and reduced no-show rates; and that readily-available transportation can prevent extra stays in the hospital and generate overall cost savings. Available data do not show exact numbers of patients affected by a lack of transportation; according to research, the range is as great as 10% to 50% of patients who report transportation as a barrier to accessing health care. Certain population groups have been identified as more likely to have transportation needs impacting access to health care. These include the elderly, those with disabilities, individuals with lower incomes, veterans using the VA’s medical system, Native Americans, patients with chronic diseases, and those living in isolated rural areas. Barriers to improving transportation access to health care include transportation infrastruc- ture issues—for example, limited or ineffective public transportation service; travel distances to access health care that are related to the location of health-care facilities in relation to the location of their patient population; and limited dialogue, information sharing, and coordi- nation between the health-care and transportation sectors that otherwise might work toward improving transportation access. While such barriers are often real, through surveys and outreach, the research project iden- tified examples of arrangements and partnerships between transportation and health-care organizations that have improved transportation access to health care. These are described in Chapters 5 and 6 of this report. Chapter Notes 1. “Access to Health Service,” HealthyPeople.gov, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. https://www.healthypeople.gov/2020/topics-objectives/topic/ Access-to-Health-Services. 2. Koh, H. and J. Rosenberg. Coordinating Community Planning for Transportation and Health. The JAMA Forum, June 25, 2019. 3. Artiga, S. and E. Hinton. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. KFF Henry J. Kaiser Family Foundation, May 10, 2018. 4. Orgera, K. and S. Artiga. Disparities in Health and Health Care: Five Key Questions and Answers. KFF Henry J. Kaiser Family Foundation, August 8, 2018.

Why Should Communities Improve Transportation to Health Care? 21 5. Workshop Proceedings: Exploring Data and Metrics of Value at the Intersection of Health Care and Transporta- tion. T. Wizemann and A. Baciu (Rapporteurs), Health and Medicine Division and TRB, National Academies of Sciences, Washington, D.C., June 2016, Remarks by TRB Executive Director Pedersen. 6. Syed, S. T., B. S. Gerber, and L. K. Sharp. Traveling Towards Disease: Transportation Barriers to Health Care Access. Journal of Community Health, Vol. 38, 2013, No. 5, pp. 976–993. http://doi.org/10.1007/s10900-013- 9681-1. 7. Locatelli, S. M., L. K. Sharp, S. T. Syed, S. Bhansari, and B. S. Gerber. Measuring Health-Related Transporta- tion Barriers in Urban Settings. Journal of Applied Measurement, Vol. 18, 2017, No. 2, pp. 178–193. 8. Health Research and Educational Trust. Social Determinants of Health Series: Transportation and the Role of Hospitals. November 2017, Chicago, IL, 2017, www.aha.org/transportation. 9. Yang, S., R. L. Zarr, T. A. Kass-Hout, A. Kourosh, and N. R. Kelly. Transportation Barriers to Accessing Health Care for Urban Children. Journal of Health Care for the Poor and Underserved, Vol. 17, 2016, No. 4, pp. 928–943. 10. Silver, D., J. Blustein, and B. C. Weitzman. Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low Income Suburbanites. Journal of Immigrant and Minority Health/Center for Minority Public Health, Vol. 14, 2012, No. 2, pp. 350–355. 11. Kelly, C., C. Hulme, T. Farragher, and G. Clarke. Are Differences in Travel Time or Distance to Health Care for Adults in Global North Countries Associated with an Impact on Health Outcomes? A Systematic Review. BMJ Open, Vol. 6, 2016, Issue 11: e013059. http://bmjopen.bmj.com/content/6/11/e013059.long. 12. Chetty, R. and N. Hendren. The Impacts of Neighborhoods on Intergenerational Mobility: Childhood Expo- sure Effects and County-Level Estimates. Harvard University and National Bureau of Economic Research, Cambridge, MA, 2015. https://scholar.harvard.edu/files/hendren/files/nbhds_paper.pdf. 13. Litman, T. 2002. Evaluating Transportation Equity. World Transport Policy & Practice, Vol. 8, 2002, No. 2, pp. 50–65. https://pdfs.semanticscholar.org/fa6c/6421f37a60cb8d4bde401ebd384ac174bc40.pdf. 14. Rides to Wellness Community Scan Project. Health Outreach Partners, 2017. https://outreach-partners.org/ wp-content/uploads/2017/06/FTA-Comm-Profiles-2.pdf. 15. Rides to Wellness, 2017, p. 3. 16. Wallace, R., P. Hughes-Cromwick, H. Mull, and S. Khasnabis. Access to Health Care and Nonemergency Medical Transportation: Two Missing Links. Transportation Research Record: Journal of the Transportation Research Board, No. 1924, 2005, pp. 76–84. 17. Pesata, V., G. Pallija, and A. A. Webb. A Descriptive Study of Missed Appointments: Families’ Perceptions of Barriers to Care. Journal of Pediatric Health Care, Vol. 13, 1999, pp. 178–182. 18. Choi, M., K. B. Adams, and E. Kahana. The Impact of Transportation Support on Driving Cessation Among Community-Dwelling Older Adults. The Journals of Gerontology: Series B, Psychological Sciences and Social Sciences, Vol. 67B, 2012. Issue 3, pp. 392–400. https://doi.org/10.1093/geronb/gbs035. 19. MacLeod, K. E., D. R. Ragland, T. R. Prohaska, M. L. Smith, C. Irmiter, and W. A. Satariano. Missed or Delayed Medical Care Appointments by Older Users of Nonemergency Medical Transportation. The Gerontologist, Vol. 55, 2015, No. 6, pp. 1026–1037. http://doi.org/10.1093/geront/gnu002. 20. Horton, S., and R. J. Johnson. Improving Access to Health Care for Uninsured Elderly Patients. Public Health Nursing, Vol. 27, 2010, No. 4, pp. 362–370. https://10.1111/j.1525-1446.2010.00866.x. 21. “How Is Poverty Status Related to Disability?” Center for Poverty & Inequity Research, University of California, Davis, 2015. https://poverty.ucdavis.edu/faq/how-poverty-status-related-disability. 22. Arcury, T.A., J. S. Preisser, W. M. Gesler, and J. M. Powers. 2005. Access to Transportation and Health Care Utilization in a Rural Region. The Journal of Rural Health, Vol. 21, 2005, No. 1, pp. 31–38. 23. Mattson, J. Transportation, Distance, and Health Care Utilization for Older Adults in Rural and Small Urban Areas. Small Urban & Rural Transit Center, Upper Great Plains Transportation Institute, North Dakota State University, Fargo, 2010. https://www.ugpti.org/pubs/pdf/DP236.pdf. 24. KFH Group, Inc. Northeast Arizona Passenger Transportation Study. Conducted for the Northern Arizona Council of Governments, 2019. 25. U.S. Census Bureau. Disability Characteristics. 2012–2016 American Community Survey 5-Year Estimates. U.S. Census Bureau. https://www.census.gov/programs-surveys/acs/technical-documentation/table-and- geography-changes/2016/5-year.html. 26. Wishner, J., P. Solleveld, and R. Rudowitz. A Look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies. KFF Henry J. Kaiser Family Foundation, July 2016. https://www.kff.org/medicaid/ issue-brief/a-look-at-rural-hospital-closures-and-implications-for-access-to-care/. 27. It Takes a Community; “Why Rural Hospitals Are Closing,” blog post by Dr. Mark Pratt, June 6, 2019. https:// www.allscripts.com/2019/06/why-rural-hospitals-are-closing/. 28. Medicaid. December 2017 Medicaid and CHIP Enrollment Data Highlights. https://www.medicaid.gov/ medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. 29. Texas A&M Transportation Institute and Burkhart, J. Interim Report, Revised Post Panel Comment TCRP Research Project B-44, “Examining the Effects of Separated Non-Emergency Medical Transportation

22 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services (NEMT) Brokerages on Transportation Coordination.” March 2014. https://groups.tti.tamu.edu/transit- mobility/files/2015/12/Interim-Report-Revised-Post-Panel-Comment.pdf 30. Abraham, T. Medicaid Waivers Put Transport Benefits on the Chopping Block. Health Care Dive, 9-7-2018. https://www.healthcaredive.com/news/medicaid-waivers-put-transport-benefits-on-chopping- block/531427/. 31. Borders, S., N. Chaudhuri, and J. Dyer Evaluation of the Texas Medical Transportation Program: Final Report. A report to the Texas Health and Human Services Commission. Public Policy Research Institute, Texas A&M University, 2009. 32. Transit Manager of Hopi Senom on the Hopi Reservation, personal communication with K. Hosen, February 2018. 33. Ellis, E., B. Hamby, H. Menninger, J. Quan, B. Powell, R. Glauthier, V. Sedig, and H. Chase. TCRP Research Report No. 164: Community Tools to Improve Transportation Options for Veterans, Military Service Members, and Their Families. Transportation Research Board, Washington, D.C., 2013. 34. MITRE Corp. Assessing the Benefits of Transportation Services to Veterans. Department of Veterans Affairs, Veterans Health Administration, Atlanta, GA, 2018. 35. Office of the Inspector General of the U.S. Department of Health and Human Services. Medicare and State Health Care Programs: Fraud and Abuse; Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements, December 2016. https:// www.federalregister.gov/documents/2016/12/07/2016-28297/medicare-and-state-health-care-programs- fraud-and-abuse-revisions-to-the-safe-harbors-under-the. 36. Billioux, A., K. Verlander, S. Anthony, and D. 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Effect of a Transportation Incentive on Compliance with the First Prenatal Appointment: A Randomized Trial. Obstetrics and Gynecology, Vol. 89, 1997, pp. 1023–1027. 44. Chaiyachati, K. H., R. A. Hubbard, A. Yeager, B. Mugo, S. Lopez, E. Asch, C. Shi, J. A. Shea, R. Rosin, and D. Grande. Association of Rideshare-Based Transportation Services and Missed Primary Care Appoint- ments: A Clinical Trial. JAMA Internal Medicine, Vol. 178, 2018. No. 3, pp. 383–389. https://10.1001/ jamainternmed.2017.8336. 45. Sviokla, J., B. Schroeder, and T. Weakland. How behavioral economics can help cure the health care crisis. Harvard Business Review, 2010. https://hbr.org/2010/03/how-behavioral-economics-can-h. 46. “Accountable Care Organizations (ACOs): General Information.” Centers for Medicare and Medicaid Services, Centers for Medicare and Medicaid Services, 2018. https://innovation.cms.gov/initiatives/aco/. 47. Premier Research Institute. 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The availability of transportation influences the ability of individuals to access health care, whether in urban, suburban or rural areas. Those lacking appropriate or available transportation miss health care appointments, resulting in delays in receiving medical interventions that can lead to poorer health outcomes. This in turn contributes to the rising cost of health care.

The TRB Transit Cooperative Research Program's TCRP Research Report 223: Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services details how to initiate a dialogue between transportation and health care providers as well as subsequent actions and strategies for pursuing a partnership and implementing transportation solutions appropriate for patients.

Efforts to improve health in the United States increasingly recognize that it’s not just the health care system that is responsible. It’s a range of factors that collectively affect health and health outcomes. These factors are known as the “social determinants of health,” and, significantly, they include transportation.

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